Maybe six months after I arrived in town, I was referred a patient with cancer of the distal esophagus. The perversity of being a surgeon is that despite the terribleness of the disease, it's hard not to be excited about the prospect of doing the operation to (hopefully) cure it. If you like doing general surgery, esophagogastrectomy pretty much has it all: the blue-plate special. First, you lay the patient on his back, and open his belly. Then you cut loose the stomach from all its attachments, tying off many many vessels, peeling it off the pancreas, separating it from the liver the colon, until it's hanging like a hammock in the breeze, suspended between the duodenum and the esophageal hiatus. You may or may not remove the spleen. If you're smart, you'll insert a feeding tube into the intestine (in case there are post op swallowing or other difficulties). I always did a very short pyloroplasty (slightly controversial: it's to prevent food from backing up in the partially defunctionalized stomach. If you make it too big, there can be a "dumping syndrome." Never saw it with a minimalist cut.)Then you sew up the abdomen and roll the patient onto his left side, after which you slash open the right chest, between the ribs. After entering the chest cavity and loosening up the lung, you dissect free the lower half of the esophagus, up to the azygous vein; then you pull the free stomach into the chest. Including the tumor in the middle, you remove the lower portion of the esophagus along with the upper portion of the stomach, and drop the sizeable chunk of tissue into a bucket for the pathologist. Then you attach the remaining esophagus to the remaining stomach and fashion a sort of collar of stomach around the anastomosis, to prevent reflux. Leaving a couple of chest tubes, you reapproximate the ribs and sew everything up.
The man was in his early 50s; a smoker (aren't they all?) but otherwise quite healthy. I explained the situation, and he agreed. What choice did he have, really?
The operation went perfectly; in fact, I think everyone in the OR was impressed. New kid in town, tackling a big operation with aplomb and dispatch. In the recovery room, the patient was stable as could be. But a two-cavity (as we like to say) operation takes a lot out of a person (no pun) and many postop difficulties are possible. Fluid shifts, heart and lung problems, pain management. I admitted him to the ICU, where I hung around for awhile, then went home assured he was doing great. My sleep was untroubled.
Until around three a.m., when the phone rang. Without any preliminary pleasantries, the nurse on the other end said "Mr. D's CVP is zero." I waited a beat, assuming there might be more info forthcoming. None. So I asked "How's his blood pressure?"
"120 over 80." (Note: perfect.) Pause, silence.
"What's his pulse?"
"76, regular." (Note: perfect.) Pause. Silence.
"OK, how much urine is he making?"
"50 - 60 cc an hour." (Note: perfect.) Pause. Silence.
"Does he have a fever?"
"No."
"So, how's his mental status?"
"He's reading a magazine."
"Well, uh, how's his oxygenation?"
"Last blood gas was fine." (Didn't have continuous oxygen monitoring in those days.) Pause. Silence.
"Gee, it sounds like he's doing great," I said. "
"A CVP of zero isn't normal," I was informed.
"Yeah, but it's really a relative number. Sounds like his volume is just fine." This was also before continuous readouts of CVP: to measure it, the patient was laid flat, a tube was filled with saline, held vertically (by eyeball) at a (hopefully) previously marked point on the neck, and the fluid was allowed to run into the patient. The point at which it stopped, in terms of centimeters above the marked point, was considered the CVP.
"You mean you're not going to do anything about it?"
"Well, really, it seems to me......" At that point I was talking to a dial tone.
What the hell just happened? The guy's fine. It's not like I'd been told his blood pressure was sixty and I'd said to give him an aspirin. Was it that her experience told her esophagogastrectomy patients don't do that well? (The surgeon in town who did most of them was, well, a bit brutal.) Was it just that she didn't know me? Was I guilty of operating a knife while young? Going back to sleep was impossible but I sure as hell wasn't going to go in to see a patient doing perfectly. I showed up, as usual, at 6 a.m.
A nurse I'd never seen before strode up to me quite purposefully. "Are you Dr Schwab," she asked (accused, really.) "Yes," I said, " and I'd like to talk......" The sentence trailed off as she turned and huffed out the door, as if I'd flashed her, or used the worst insult in my lexicon. Meanwhile, the only way in which my patient's status had changed is that he was now reading the morning newspaper. I sought out the head nurse. She seemed already to know what had gone on. "Geez," I said. "It's not like I ignored the guy. Look at him -- he looks like a damn visitor." The head nurse looked me in the eye and said, slowly, deliberately, with pained forbearance: "Our EVERETT physicians would have DONE something about a CVP of zero."
I was the ventriloquist's dummy, hand up my rear, mouth moving, no words forthcoming. I was the car on the side of the road, transmission splattered on the asphalt. I was a clubbed fish, a wet finger in a socket. I was so beyond speechless, I was prehistoric. Australopithecus, Neanderthal. Homo incredulous. The head nurse, having emptied her quiver, retreated to more important matters. Trembling with a mixture of anger and befuddlement, I reached for the patient's chart and wrote orders to transfer him the hell out of the ICU. The hospitals in town have since combined, but at that time there were two. I resolved never to admit a patient again to that one if it was likely he'd need intensive care. And I didn't for some time. Eventually we got to know each other, and things smoothed out. The patient, I might add, continued on his trajectory and was discharged in record time.
In my opinion, ICU nurses are among the finest there are, and I've always gotten along with them -- more than got along: most were buddies. Their job is a really tough one, and a good ICU nurse is thing to be cherished, nurtured: nay, worshipped. Which, in general, I did. They came to me when they or their family needed surgery. But not that night nurse. Never saw her again. And my colleagues, whenever the opportunity presented itself, loved to regale me with "Our EVERETT physicians...."
24 comments:
Haha, that was a great story. :)
Between you and Barbados Butterfly, I'm beginning to think I might need to be on my guard around ICU nurses. ;)
Did the patient quit smoking?
One of the first cases I saw on my surgery rotation was an esophagectomy with distal colonic interposition. Incredible procedure. I fell in love with general surgery (as opposed to gynecological) that day: to be able to get into so many parts of the body for just one surgery!
The man was an engineer. The experience convinced him that the data were on the side of quitting.
And yes, it's quite amazing to be able to do those things: it's a testimony to the resilience of the body, and its ability to heal itself. And knowing the secrets that allow such manipulation is exciting and humbling. Not to mention: fun.
This was an amazing post! First of all for its content, and your own obvious pleasure in relating it, and then for the humor!
How does someone like that nurse manage to hang on to a job? I would think that an attitude like that would eventually cause them to become a liability in some ways.
By the way ... I love graphic you found to go along with the post! :o)
I eventually had a meeting with the hospital nursing director, who encouraged me to resume admitting patients. She said the nurse in question had used up about 8 of her 9 lives.
And yeah, I find it pretty funny now.
There are several interesting lessons in that story. Higher-level decision-making requires the ability to understand which findings need to be addressed on their own merit, and which finding can be correlated with other findings. Generally, the axiom of treating the patient rather than the test results is best. How people deal with unmet expectations reveals a lot about their character.
I enjoy your stories and the lessons they hold.
Why do docs have to be nice to nurses? The worst that can happen is that the nurses will think the doc is a dick/bitch (excuse my language please). They still have to care for the patient the same as if it was Dr. Sunshine, right?
Everett is where I live. It's like saying "Our Brisbane physicians...."
Hmm. Comments deleted by author... Wonder what they were? A first time occurence! (Author means the person that wrote it, not me.) One can only wonder...
I must say I am dumbfounded. I was a nurse up until 6 years ago, and I am not quite sure I would have handled that situation with as much grace as you did. Sometimes I would be on shift with a nurse who wasn't the best at assessments. On some occasions, one of them might say "I must page Dr. So and So...my patients pulse ox is 70%" Normally, that would be cause for alarm.I would walk into the room, and there would be the patient sitting up in bed as pink as could be, speaking, breathing normally and what not...."Gee, did you LOOK at the patient, or just at the equipment?" Then, low and behold, there is the sensor, monitoring the patient's sheets....that would happen not infrequently. There sometimes is too much focus on the technology, and not on the exam.
I learned an important lesson in my ED rotation: don't treat the lab, treat the patient!
Sounds like this was analogous.
Sid, I love your blog and your book - both are a great read! Thank you for taking the time to write. :)
Dr. Schwab-
In regards to the medical director for Grey's Anatomy...I was curious so I looked into it. Her name is Elizabeth and oddly enough, nowhere in her bio's does she list any letters behind her name...hmmm. http://www.greyswriters.com/2006/04/from_elizabeth_.html
Hmm. Love the story, but I have mixed emotions. On one hand, it's comforting to know that even doctors have to put up with surly nurses, but then on the other hand it's not so comforting to think that even doctors have to put up with surly nurses.
I agree though that I've met some wonderful nurses - quite a few actually (my sister's a CCU nurse). And when it comes to teaching, some of them are incredible! But, boy oh boy can a mean nasty nurse who clearly needs to find a new profession really ruin your day.
Mean nasty and surly are adjectives not limited to nurses, of course. :-)
Fortunately, most critical care nurses know what they're doing and develop a 'look at the patient first' mentality when it comes to monitoring and observation. CVP is one of those 'trend is more important than stat' values, and it can be so variable depending on line position, patient position, phase of the moon, etc. :)
It's not limited to ICU (or to nurses, for that matter...) I did once work with a ward nurse who insisted that a 2 year-old patient needed oxygen because his SpO2 showed 88%.
"But he's jumping up and down in the bed. Look at that waveform, it's all over the place!"
"This monitor is always accurate, it's unaffected by motion."
"He's jumping. Up and down. In the bed."
Luckily the patient survived ;)
Oh boy, it’s nurses like this that make the rest of us look like idiots. When I was a student nurse, I had a doctor tell me that when it comes to a patient’s health, “Breathing is very important.” His statement was in regards to technology. He said a machine might be telling you that a patient is all right, but in reality, the patient may not be breathing. He’s message was clear; use your eyes, ears, and common sense. Obviously, the nurses you were dealing with didn’t get it.
Get story, dumb nurses.
Mother Jones RN
Did he have adenocarcinoma from barrett's? I wondered because you said it was in the distal esophagus. I have Barrett's with dysplasia, but I have always been told it was from GERD. I don't smoke, and havent for many years.
Cathy: he did not have Barrett's. I did operate on a man who'd been surveyed regularly -- which is what needs to be done (whether antireflux surgery is useful is controversial, but a consideration) -- and in whom a very early cancer was found. He did great. Cured.
Remember the days whe eyes, ears, hands nose (nothing like eau de Pseudomonas) and cognitive ability were the best "monitor"
Oh my god...my stomach hurts from laughing.
Yes, the nurse was a total dork, it's the way you described it that was hilarious. Sounds like it was a departmental attitude, as the head nurse (let's not discuss where said head was located) agreed with the staff nurse!
"He's reading a magazine."
Gee, isn't a CVP of zero, like....dead? LOLOL!
Sorry you had such a bad experience, but congratulations on a surgery well done!
Unfortunately I've worked with more than a fair share of ICU nurses who, shall we say, have a somewhat limited focus.
ICU can actually *attract* those sorts. Funny, that.
Sitting up. Reading the newspaper. BP 120/80. CALL A CODE!
I recently had an astounding experience with a hospitalist, an internist. I'd mentioned at some point in the ER that I obtained a medication that had been prescribed for me for years (not a narcotic, antidepressant or anything of that sort) over the internet. She hounded me thereafter as being clearly demented (I experienced a period of delirium during this medical crisis) and needing a court appointed guardian...all said very accusingly, reminding me that it is "illegal". The medication had nothing to do with the crisis, according to the specialists, and I did the neuropsychological of several hours in my room with a psychologist which showed I had no mental defects. But that cut no ice with her; she didn't ever let up til I was discharged. And never once asked me how I was doing, or talked to me about the medical issues I was dealing with. I have never, ever met a doctor who behaved so bizarrely and hatefully. I really cannot imagine I'll meet her like ever again. Okay...it is illegal (and I'm well aware of the risks), but should that have been a physician's focus? Her behavior was frightening and maddening. I did complain to my doctor, but was so angry that when I got a Press-Ganey survey in the mail (first time ever) I didn't send it in. My doc has promised me she'll never come anywhere near me should I have to be hospitalized again. Maybe I've been incredibly lucky -- every doctor, every nurse I'd ever dealt with were the best in the world, in my opinion.
I have an interesting story to get me to this comment. But here's the short version: Had this same surgery with colonic interposition and loss of my spleen. Big operation Big pain. My epi fell out and the nurse would not give me additional pain meds because I agreed with the anesthesia resident that we would 'manage' the pain with other methods. She insisted that I had decided to manage with current pain meds schedule. By the time the morning came I was a quivering, whimpering mess, but did finally get pain meds to cover the lost epi.
Most nurses in the journey have been wonderful and do an incredible job under hard circumstances. Still fighting the pain beast, but now 5 weeks post surgery and trying to train my former bowel section to be an esophagus and stomach.
After reading another one of your blogs it now has me gagging when I burp and trying to forget the 'smell' of bowel. I need a better mental or better yet odor picture to live the rest of my life with!
Thanks for commenting, Brenda. A less-than-ideal experience, to say the least! You're still very early in the recovery process, and it sounds like you're off to a great start, other than the hospital part of it.
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